NOTICE OF
PRIVACY PRACTICES
Smith Family Dental Solutions
301-B Keisler Drive Cary, NC 27518
PATIENT CONSENT FORM
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:
• TREATMENT (including direct or indirect treatment by other health care providers involved in my treatment);
• Obtaining PAYMENT from third party payers, such as my insurance
companies and me, your patient;
• The day-to-day HEALTHCARE OPERATIONS of your practice.
I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices (NPP), which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.
I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carryout treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.
I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date, I revoke this consent is not affected.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL/DENTAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
We understand that your health information is personal to you, and we are committed to protecting the information about you. This Notice of Privacy Practices (or “Notice”) describes how we will use and disclose protected information and data that we receive or create related to your health care.
Our Duties
We are required by law to maintain the privacy of your health information, and to give you this Notice describing our legal duties and privacy practices. We are also required to follow the terms of the Notice currently in effect. We are required by law to notify you following a breach of the privacy of your health information.
How We May Use And Disclose Health Information About You
Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately, as discussed below. Patient files may be stored in open file racks and will not contain any information that is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination rooms, etc. Those records will not be available to persons other than the office staff.
We will not use or disclose your health information without your authorization, except in the following situations:
Treatment: We will use and disclose your health information while providing, coordinating or managing your health care. For example, information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. We may also provide other health care providers with your information to assist him/her in treating you.
Payment: We will use and disclose your medical information to obtain or provide compensation or reimbursement for providing your health care. For example, we may send a bill to you or your health plan. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies ;used. As another example, we may disclose information about you to your health plan so that the health plan may determine your eligibility for payment for certain benefits.
Health Care Operations: We will use and disclose your health information to deal with certain administrative aspects of your health care, and to manage our business more efficiently. There may be inspections of our office and review of documents, which may include your protected health information by insurance payers and government agencies in the normal performance of their duties.
Business Associates: There are some services provided in our office through contracts with business associates. We may disclose your health information to our business associates so they can perform the job we've asked them to do. However, we require the business associate to sign a confidentiality/business associate agreement to protect your health information.
Notification of Family: We may use or disclose information to notify or assist n notifying a family member, personal representative, or other person responsible for you care of your location and general condition.
Communication with Family: We may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person's involvement in your care.
Funeral Director, Coroner, and Medical Examiner: Consistent with applicable law we may disclose health information to funeral directors, coroners, and medical examiners to help them carry out their duties.
Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events, product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability, including child abuse and neglect.
Victims of Abuse, Neglect or Domestic Violence: We may disclose your health information to appropriate governmental agencies, such as adult protective or social services agencies, if we reasonably believe you are a victim of abuse, neglect, or domestic violence.
Health Oversight: In order to oversee the health care system, government benefits programs, entities subject to governmental regulation and civil rights laws for which health information is necessary to determine compliance, we may disclose your health information for oversight activities authorized by law, such as audits and civil, administrative, or criminal investigations.
Court Proceeding: We may disclose your health information in response to requests made during judicial and administrative proceedings, such as court orders or subpoenas.
Law Enforcement: Under certain circumstances, we may disclose your health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official.
Threats to Public Health or Safety: We may disclose or use health information when it is our good faith belief, consistent with ethical and legal standards, that it is necessary to prevent or lessen a serious and imminent threat or is necessary to identify or apprehend an individual.
Workers Compensation: We may disclose health information when authorized and necessary to comply with laws relating to worker’s compensation or other similar programs.
Other Uses: We may also use and disclose your personal health information for the following purposes:
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To contact you to remind you of an appointment for treatment;
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To describe or recommend treatment alternatives to you;
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To furnish information about health-related benefits and services that may be of interest to you; or
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For certain charitable fund raising purposes.
Prohibition on Other Uses or Disclosures
We may not make any other use or disclosure of your personal health information without your written authorization. Other uses or disclosures that would require your authorization include, for example, use of psychotherapy notes, and marketing with or sale of your health information. Once given, you may revoke the authorization by writing to the contact person listed below. Understandably, we are unable to take back any disclosure we have already made with your permission.
Individual Rights
You have many rights concerning the confidentiality of your health information. You have the right:
To request restrictions on the health information we may use and disclose for treatment, payment, and health care operations. We are not required to agree to these requests. To request restrictions, please send a written request to the address below.
To receive confidential communications of health information about you in a certain manner or at a certain location. For instance, you may request that we only contact you at work or by mail. To make such a request, you must write to us at the address below, and tell us how or where you wish to be contacted.
To inspect or copy your health information. You must submit your request in writing to the address below. If you request a copy of your health information, we may charge you a fee for the cost of copying, mailing or other supplies.
To amend health information. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, you must write to us at the address below. You must also give us a reason to support your request. We may deny your request to amend your health information if it is not in writing or does not provide a reason to support your request. We may also deny your request if:
The information was not created by us, unless the person that created the information is no longer available to make the amendment,
The information is not part of the health information kept by or for us,
Is not part of the information you would be permitted to inspect or copy, or
Is accurate and complete.
To receive an accounting of disclosures of your health information. You may submit a request in writing to the address below. Not all health information is subject to this request. Your request must state a time period, no longer than 6 years and you may not include date before April 14, 2003. Your request must state how you would like to receive the report (paper, electronically). The first accounting you request within a 12 month period is free. For additional accountings, we may charge you the cost of providing the accounting. We will notify you of this cost and you may choose to withdraw or modify your request before charges are incurred.
To receive a paper copy of this Notice upon request, even if you have agreed to receive the Notice electronically. You must submit a request for a paper notice in writing to the address below.
All requests to restrict use of your health information for treatment, payment, and health care operations, to inspect and copy health information, to amend your health information, or to receive an accounting of disclosures of health information must be made in writing to the contact person listed below.
Complaints
If you believe that your privacy rights have been violated, a complaint may be made to our privacy officer at (919) 854-4344 or the address listed below. You may also submit a complaint to the Secretary of the Department of Health and Human Services. We will not retaliate against you for filing a complaint.
Contact Person
Our contact person for all questions, requests or for further information related to the privacy of your health information is:
Contact Officer: Erin Weidner
Telephone: 919-854-4344
Fax: 919-854-4340
E-mail clinicalteam@sfdcary.com
Changes to This Notice
We reserve the right to change our privacy practices and to apply the revised practices to health information about you that we already have. Any revision to our privacy practices will be described in a revised Notice that will be posted prominently in our facility.
Notice Effective Date: October 25, 2014